Heroin addicts face high treatment costs, tough decisions

Jun. 7, 2014

Henry Augustine of Appleton has been clean for sixth months, overcoming heroin addiction with an abstinence-based program after relapsing following stints in five treatment programs built around medication or behavioral therapy. / Dan Powers/Gannett Wisconsin Media

Resources needed

Wisconsin has many treatment options available for drug users seeking sobriety, but the state is lacking resources on several key fronts, experts say. There is disagreement on the most effective treatment for heroin addiction, so the opinions on what services are needed also vary. Here are several needs identified by treatment experts interviewed for this story. Dedicated treatment facilities: The detoxification process can be hell for heroin addicts, taking up to a week to get through the initial withdrawal. But Louis Oppor, a state Department of Health Services section chief specializing in substance abuse, said Medicaid and many private insurances won’t pay for this to be done in a hospital since the process is not life-threatening. The prospect of solo withdrawal is daunting for drug users. A package of heroin bills signed into law in April by Gov. Scott Walker includes money for three rural opiate treatment centers that will offer detox programs as well as counseling and medical or abstinence-based treatment. Cost will be on a sliding scale based on ability to pay. Oppor said the state gets calls frequently “looking for more intensive opiate treatment care than what most places in the state can offer right now.” Sober-living houses: Addicts who finish in-patient treatment need continued support to stick to sobriety, and experts say low-cost sober living houses can be key. Recovering addicts live together and support each other, but costs remain low because the facilities have no full-time staff. Oxford House is among organizations providing this service, with 10 homes in Madison and 10 others in cities including Green Bay, Stevens Point and Wisconsin Rapids. But many communities have no such option nearby, so several Oshkosh and Appleton organizations are working to establish three sober living homes between the two communities, two hopefully operational by year’s end, said Hugh Holly, executive director of Nova Counseling Services in Oshkosh. Addiction treatment doctors: Addiction affects more than 10 percent of the American population — including the 4 percent on heroin and other opiates — but there are only 5,000 doctors certified to treat addiction in the country, said Dr. Michael Miller, medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Oconomowoc and a frequent lecturer on addiction treatment. Oppor said Wisconsin particularly needs doctors certified to prescribe buprenorphine, a drug similar to methadone that relieves cravings by binding to the opioid receptors heroin would use. Wisconsin has 185 doctors and 60 treatment programs authorized to use buprenorphine (commonly known by the brand name Suboxone). Federalregulations limit availability of the drug, though, with doctors only able to prescribe buprenorphine to 100 patients at a time.

Where to find help

PROVIDERSA database of local drug addiction resources is available at www.findtreatment.samhsa.gov, a website maintained by the U.S. Substance Abuse and Mental Health Services Administration. ADVICEExperts say the first step is simply visiting a primary care doctor or county human services agency. They are the people most knowledgeable about quality programs and most familiar with treatment options. “Don’t just buck the system and go off to some place that advertises it’s in a pretty location and it has horses on site,” said Dr. Stuart Gitlow, president of the American Society of Addiction Medicine. “Go someplace because your addiction doc has told you that’s a good place to go.” Medical societies and hospitals can also provide referrals. Dr. Mark Kraus, co-chair of the American Society of Addiction Medicine’s Patient Advocacy Task Force, added that drug users must remember they have a chronic condition. “There is hope — people can and do get better,” he said. “It is a chronic disease, which means there’s remissions and relapses.”

About this report

This story is part of our ongoing “Deadly Doses” series, which examines the spread and impact of heroin across Wisconsin. Sunday: Treatment options varied, costly, lacking Monday: Douglas Darby has spoken to 10,000 students warning of the horrors of heroin use

Heroin medication

Three drugs are widely used to treat heroin addiction: • Methadone — an opiate — attaches to opioid receptors in the brain that would be used by heroin and reduces cravings for the drug. It has long been used to help addicts return to normal life, but it also has a history of being sold illegally, abused and causing overdoses. • Buprenorphine (known by the brand name Suboxone) works similarly to methadone but has been tweaked to make it more difficult to abuse. It is also more widely available than methadone, which is highly regulated. • Naltrexone (known by the brand name Vivitrol) is essentially a vaccine, blocking opioid receptors to prevent heroin from creating a high. Providers say it can also cause depression in some users since it blocks natural opiates as well.

More

ADVERTISEMENT

Henry Augustine’s journey to sobriety took him to the far corners of the country, but left him back where he started.

A month-long stay at an Oshkosh counseling center was followed quickly by a relapse. A six-month Arizona program ended after a month when he left and shot up with heroin. A medication-assisted program in California kept him clean for three months before another relapse.

Even totaling his car while overdosing on heroin and a prescription drug in 2012 didn’t deter the 20-year-old Appleton man.

“There were still these reservations inside that I could still control my using,” Augustine said. “I did (treatment) until there was something I didn’t want to do, and I wouldn’t do it.”

Wisconsin’s heroin epidemic has spawned a growing number of addicts in need of treatment, but the varied treatment philosophies leave them and their families with a bewildering array of options. Cost is also a major hurdle, as insurance companies often refuse coverage or create barriers not present for traditional ailments such as cancer or heart disease.

The state also lacks resources to treat heroin users in several key areas. Experts say Wisconsin needs more treatment providers, post-treatment sober living houses and centers dedicated to opiate treatment — particularly to aid in the detoxification process, which is excruciating for addicts but does not usually qualify for hospital treatment.

“All too often, people with an addiction are looked at — when they relapse, or even when they go to treatment — that it’s some kind of moral failure on their part,” said Kathi Cauley, director of the Jefferson County Human Services Department, which has operated a treatment program for heroin and other opiates since 2007. “This is a disease. Yes, people make lousy choices and try it for the first time, but the addiction to it happens so fast that it truly is a disease after that.”

(Page 2 of 4)

Treatment approaches vary

Efforts to combat heroin addiction fall into three basic categories:

• Medications to lessen cravings and block the ability to get high.

• Counseling and behavioral therapy to help users develop coping mechanisms and establish new habits.

• Abstinence-based group programs that provide a support network of those facing similar struggles.

Experts say the best success rates often come from combining several approaches, though they note everyone’s addiction and path to sobriety are unique.

In all, five addiction programs rooted in medication or behavioral therapy failed to get through to Augustine, but he has found success in the 12 steps of Narcotics Anonymous and Alcoholics Anonymous. He is attending meetings five days a week and finally taking ownership of his disease.

“I just really wanted it more for myself for the first time; (I) didn’t do it for anyone else,” said Augustine, who has been sober for the past six months. “I realized for the first time I was going to die if I continued doing that.”

But lack of standardization in treatment is also a problem — leading to inconsistent quality, said Dr. Michael Miller, medical director of the Herrington Recovery Center in Oconomowoc and a frequent lecturer on addiction treatment.

“(We need to) raise the floor, to say that ‘Across the board, everybody should get at least this,’” Miller said. “We are decades behind cancer treatment and treatment of heart disease as far as standardization.”

Ralph Dixon of Wausau said he and his wife sought out a detoxification program immediately after learning their son, Michael, was using heroin several years ago. They said they paid $10,000 for a three-day program with no follow-up care.

“Now in hindsight, three-day detox for heroin is a joke,” Ralph Dixon said.

Cost a deterrent

When Michael Dixon’s heroin use continued more than a year later, his parents discovered longer in-patient programs often cost about $5,000 per month, which Ralph Dixon said was impossible. Others share their frustration.

(Page 3 of 4)

“We get calls every day from people that want to come but can’t pay for it,” said Hugh Holly, executive director of Nova Counseling Services in Oshkosh.

Tyler Luedtke, a substance abuse counselor at Libertas Treatment Center in Green Bay, said one woman wanting in-patient help was shooting heroin almost daily but was denied insurance coverage because she “hadn’t failed enough at outpatient yet.”

Dr. Stuart Gitlow, president of the American Society of Addiction Medicine, said it is difficult to convince insurance companies to cover a disease over which the patient has some direct control — unlike diabetes and other chronic diseases. When insurance companies do offer coverage, Miller said there are more restrictions.

“There are a lot of hoops to jump through, and it’s very frustrating for subscribers and patients and families,” Miller said.

Some treatment providers hope to see improved coverage in the wake of the Mental Health Parity and Addiction Equity Act, which bars insurers from limiting mental health and substance abuse benefits more than medical or surgical benefits. Rules enforcing the 2008 federallaw were finally issued in November and will take effect in July, but Miller said litigation will likely be needed as insurance companies “try to avoid the mandate.”

The Affordable Care Act has also increased access to insurance for drug users in their 20s, resulting in more seeking treatment for opioid addiction, Miller said.

Medication divisive issue

Some providers and addicts remain skeptical about using a pill to treat drug addiction, but many who treat heroin addiction in Wisconsin say medication is an indispensable weapon in the fight for sobriety.

(Page 4 of 4)

The three widely used drugs are methadone, buprenorphine and naltrexone, which reduce cravings and prevent heroin from creating a high.

“The medication just helps keep them comfortable enough to manage, so they don’t relapse before they even finish treatment,” said Nancy Ellis, clinic director of Wausau Health Services, a methadone clinic.

Miller said he strongly urges every patient who leaves his rehabilitation center to take medication, adding some people need that regimen for the rest of their lives. Miller recommends medication and professional followup for at least two years — approximately the time it takes the brain to return to a normal state after drug use is halted.

But Michelle Devine Giese, who runs a nonprofit company that provides recovering addicts with jobs in a supportive environment, said behavioral therapy should be 90 percent of treatment.

“If you continue to take a drug like methadone or (buprenorphine)… it’s impeding the actual recovery process of changing how we are reacting and relying on another chemical,” said Devine Giese, president of Step Industries in Neenah.

Miller said medication options are limited because there has been little research on the neurobiology of addiction recovery. The field has grown in the last few years, but it remains understudied because government officials have “more empathy” for diseases like cancer and HIV, and pharmaceutical companies worry new drugs won’t be used enough to be profitable, he said.

Support key to recovery

Louis Oppor, a state Department of Health Services section chief specializing in substance abuse, said the best chance of long-term success comes from following initial treatment with “wraparound services” to meet employment, legal and family needs.

Those services at the state level are provided by Comprehensive Community Services, which currently operates in 26 counties but is expanding to the rest of the state. Private organizations like Neenah’s Step Industries also help provide a critical support network.

Michael Dixon, Ralph Dixon’s son, ended up in a state-run program designed for inmates nearing prison release.He was released in March 2013, but crashed while overdosing on heroin the next day. Michael Dixon died. His 4-year-old son was critically injured.

“They basically treat you, pat you on the fanny and send you out the door,” Ralph Dixon said. “We find out now the first 48 hours after you are released are absolutely crucial, but nobody told us that.”